Bond Eye Associates - LASIK Quiz

1

What is your current age?* This field is required.

Under 18

18 - 39

40 - 59

60+

2

Are you in good general health?* This field is required.

YESNO

3

Do you currently wear...* This field is required.

Glasses

Contacts

Glasses & Contacts

Nothing

4

Without corrective lenses, do you have...* This field is required.

Trouble seeing far away

Trouble seeing up close or with reading

Overall blurry vision both distance and near

5

Are you being treated for severe dry eyes?* This field is required.

YESNO

6

Have you ever had eye surgery?* This field is required.

YESNO

7

Have you ever been diagnosed with astigmatism?* This field is required.

Yes

No

I don't know

8

Have you ever been diagnosed with cataracts?* This field is required.

YESNO

9

What is your name?* This field is required.

First Name

Last Name

10

What is your phone number?* This field is required.

Area Code

Phone Number

11

What is your email address?By including your email address, you are providing consent for Bond Eye Associates to send you marketing emails in the future.

example@example.com